Registration: Request Triple P One-on-One

 

To request Triple P One-On-One and be matched with a trained Triple P Practitioner who will call you to set up your first appointment, fill out our Triple P One-on-One Request form.

For more information about how we safeguard your personal information, please review the Terms and Conditions at the end of this form.

 

We are collecting the following personal and demographic information about you and your family so that we can provide services to meet your family's unique needs.

By submitting the registration form, you are consenting to release the personal health information contained in it to Triple P Sudbury Manitoulin, so that we can provide the appropriate service for your child/teen. We are committed to confidentiality and all information gathered will be maintained in a secure manner.

 

USER INFORMATION
Title:
First Name:
Last Name:
Date of Birth:
1
Address:
Area:
City:
Province:
Postal Code:
By providing an email address, you are consenting to the City of Greater Sudbury and its Triple P partners sending you a confirmation and other email messages relating to the service you have requested. Do you wish to provide an email address?:
  Yes    No  
Daytime Phone Number (or contact number):
In Triple P Programs you will be asked to focus on the behaviours of one child/teen as you learn and practice new parenting strategies. Please fill in the child/teen fields about the child/teen you wish to focus on in Triple P sessions.
Child/ Teen's Name:
Child/ Teen's Sex:
What is your relationship to the child/ teen?:
Child/ Teen's Age:
Briefly describe your parenting concern.:
Will any other adults from your family also be attending sessions (examples: other parent, grandparent or caregiver)?:
Does your child/teen attend school or licensed child care:
  Does not attend school or licensed child care  
  Attends school  
  Attends licensed child care  
Please check if your child/ teen has been diagnosed with, or is currently being asessed for, any of the following:
  None  
  Autism Spectrum Disorder/PDD  
  Physical Disability  
  Speech, Language and/or Communication Challenges  
  Developmental Disability (ex. Down's Syndrome)  
  Socio-Emotional Diagnosis (ODD, Anxiety, ADHD)  
  Learning Disability  
  Brain Injury  
  Other  
Is your child/ teen currently involved with or had previous involvement with another professional or agency?:
  No    Yes  
Is the child/ teen living with you?:
  Yes    No  
What is your preferred language of service?:
  English    French  
What time of day could you attend a program or meeting?:
  None  
  Day time  
  Lunch hour  
  Evening  
To help us better understand the demographics of families using Triple P Services, please tell us how many children/teens (including the child you named above) are currently living at home with you.
Number of children at home under 4:
Number of children at home aged 4-6:
Number of children at home aged 7-10:
Number of children/ teens at home aged 11-13:
Number of teens 14 to 17:
How did you hear about Triple P?:
Do you give permission for Triple P Sudbury Manitoulin to use your demographic information (e.g. postal code, age and # of children in your family) for the purposes of planning, research, evaluation and monitoring of the effectiveness of Triple P? :
Do you give permission for Triple P to contact you for feedback regarding its services?:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
FOR OFFICE USE ONLY
Was this registration inputted by a staff person? (OFFICE USE ONLY):
  Yes    No  
Date Referred (OFFICE USE ONLY):
Referred to (OFFICE USE ONLY):
Date Contacted (OFFICE USE ONLY):
What service was provided? (OFFICE USE ONLY):
Sessions Completed (OFFICE USE ONLY):
Service Start Date (OFFICE USE ONLY):
Service Completed Date (OFFICE USE ONLY):
Tip Sheet(s) Used? (OFFICE USE ONLY):
  Yes    No  
Staff Comments (OFFICE USE ONLY):
___________________________________________________________________________________________________________
Enter the Security Code:
I agree to the terms and conditions:
Read Terms & Conditions